| Form number |
Title |
Format |
| Compound Drug |
Compound Drug |
 |
| Pharmacy Paper Claim |
Pharmacy Paper Claim |
|
| PHARM-01 |
Pharmacy Claim |
|
| PHARM-02 |
Compound Prescription Drug Claim |
|
| PHARM-03 |
Pharmacy Paid Claim Adjustment Request |
|
| PHARM-04 |
Universal Petition for Medication Authorization |
|
| PHARM-06 |
Petition for Tuberculosis Related Therapy Authorization |
|
| PHARM-07 |
Petition for Synagis Authorization |
|
| PHARM-07S |
Supplemental Synagis Dosing Form |
|
| PHARM-08 |
Medication Therapy Management Services Prior Authorization Request |
|
| PHARM-09 |
Medication Therapy Management Services Referral Form |
|
| PHARM-11 |
Statement of Medical Necessity for Brand-Name Drug Override |
|
| PHARM-12 |
Statement of Medical Necessity for Early Fill Override |
|
| PHARM-13 |
Statement of Medical Necessity for Quantity Limit Override |
|
| PHARM-14 |
Statement of Medical Necessity for Xolair |
|
| PHARM-16 |
Pharmacy Lock-In Referral |
|
| PHARM-17 |
ESA Petition |
|
| PHARM-17A |
ESA Treatment Continuation Form |
|
| PHARM-18 |
Outpatient Medication Petition |
|
| PHARM-19 |
GH Supplemental Info |
|